Understanding Value

There has been, for decades, an ongoing battle between clinical excellence and financial prudence.  Many a clash between Director of Finance and Quality Leads have resulted in the hostile death of quality improvement initiatives and projects throughout the land.

This constant battle has seen both parties protest there to be a complete lack of understanding from their counterparts.  So why, still, do we still face the challenge of both sides putting down their arms and attempted to "listen" to the perspective of their embattled 'rival'?  Why are we still struggling to understand how to balance cost with quality?

The Harvard Negotiation Project was started in 1979 to investigate the most effective way to negotiate and resolve conflict.  It produced a series of enlightening texts and the discussion of 'boundary conditions'.  It suggests the key is, amongst other things, to attempt to understand the perspective of the person you are negotiating with. I'm sure many will read that and think "yes?! of course it is?!" but ask yourself this - "when was the last time during a professional conflict you sat aside your own beliefs on a subject, actually listened to the opposing arguments, found a way to understand their argument and changed your position to accommodate it?".  My experience, and the fact that we are still seeing this battle between cost and quality suggests that happens almost never in the NHS.

RightCare began an approach to shift the focus away from conversations centred purely on finance or clinical excellence and encouraged all of those involved in service delivery and quality improvement to shift towards 'Decisions of Value'.  That is, to ensure they are making “...decisions with a clear and measurable impact on both finance (costs) and quality (care)”.

There are some extremely important considerations when you are attempting to achieve this balance.  The first is the 'law of diminishing returns' which suggests that there is a certain point at which the level of profits or benefits gained is less than the amount of money or energy invested.  Understanding this enables anybody starting a project to consider what quality standards they should set and how much resource to invest.

This is important because it suggests that there is a limit to how effective you can be, and that striving for perfection doesn't mean that you deliver the benefit you hope it will.  If we take the example of Physiotherapy and a patient with osteoarthritis of the knee.  Exercise has been proven to be of significant benefit in a large percentage of that population....to a point.  Most of us would then recognise that where conservative measures have been unsuccessful, a surgical intervention of "total knee replacement" (TKR) represents the best value for those patients.

Overkill

Many clinicians (mostly specialist clinicians who have invested a lot in becoming a specialist) often believe that all clinicians (or service development projects) must provide the "highest" level of clinical quality to be of any "value" to the system.  In other words, they often become perfectionist, and begin demanding higher "standards" for a population that does not need it, nor can we afford to provide.  In my head I can hear, as I write this, a number of clinicians say "this is healthcare, this is people lives, it has to be the highest level of quality ".  Anybody who knows me, knows that I do demand the highest standards of care from both myself and from others - but again it's about providing highest standard of care that is appropriate for the needs of the patient. ,

"Standards of care" is key here.  The problem is that many clinicians (of which I am obviously one) often associate "highest standards" with "more".  We often end up with "too much" in some places, which inevitably leads to too little in others.  The problem is therefore, not the level of perfectionism in clinicians or the fact they strive and demand the highest quality, but how and to whom they are applying their 'highest standards' or how we define "quality".

Quality

Donabedian defines quality as "the degree to which a service meets pre-set standards of goodness"

Source: Donabedian A, personal communication.

This definition is important, for it suggests that in order for a service to provide quality, it must meet its "preset standards of goodness".  Note that it does not say it must meet the "highest standard of goodness".  That is because the level of quality is dependent on the "needs" of the patients using that service, and both those 'needs' and the 'standards' will vary depending on patient and service.  Therefore, it is perfectly acceptable to have a service that offers very little in the way of clinical expertise IF that level of clinical expertise is appropriate to meet the needs of the users of that service.  To put this even more simply, it is perfectly acceptable to offer "less", providing that "less" meets the needs of the patients.  Failure to recognise this is what leads to significant unwarranted clinical variation.  If one service can provide "less" in terms of input (and therefore cost) and still achieve the preset "standards of goodness", why is there a need to demand "higher standards of quality" that will ultimately provide no further benefit, but incur significant additional cost.  Simply put, why is there a need to provide more if the preset standards of goodness can be achieved with less?

RightCare summarise this in such a way that it is best just to take an extract straight from their Atlas of Variation Compendium (2015):

"In the second NHS Atlas of Variation in Healthcare (November 2011), the classic diagram, originated in 1980 by the late Professor Avedis Donabedian, was reproduced to show that when resources are invested in increasing amounts by those responsible for paying for healthcare, the intervention is offered to people in the population who are less severely affected. As a result, the benefit gained from the intervention overall flattens off (known as the Law of Diminishing Returns), whereas the amount of harm done increases in proportion to the level of investment."

"This effect occurs independent of the quality and safety of the service. Although the levels of quality and safety will influence the relative position of the two lines, they will not affect the basic relationship. As more healthcare is provided to the population, the benefits will plateau, whereas the harmful or adverse effects will continue to increase until a point of optimality is reached. If resources are invested beyond the point of optimality, the economic value of the investment for the population, including tax-payers, will decline from high to low value through zero to a negative value"

"This decrease in value has important implications for individual patients. As the amount of resource increases and treatment is offered to more individuals who are less severely affected, for each of those individuals the balance of benefit to harm associated with a single intervention, such as knee replacement, cataract surgery or the prescription of statins, also changes. In general, the magnitude of the benefit that an individual can expect will diminish, whereas the probability and magnitude of harm remains the same, and a clinical intervention can move from being necessary or appropriate to being inappropriate or futile"

Basically, there is a point at which you are providing "too much" for the needs of that individual and to continue to do so actually increases the chance of harm. Providing "too much" not only increases the risk of harm, but is also a form of "waste".  When resources are expended for no additional benefit, they are wasted at the expense of individuals who, if used more appropriately, could have received the benefit.  A prime example of this is opioid use in chronic pain.  They can be a useful form of intervention for "some" patients, in very specific circumstances, for limited amounts of time.  However, we have entered a period of huge 'over use', in which they are providing little benefit to much of the population who have become addicted to them.  The response from many GP's is "but what other option is there, we can't just do nothing".  To which the reply is, not only CAN you do nothing, but it is the only ethical, moral and economical option.  The Hippocratic oath "first do no harm" couldn't be more appropriate here.  It is actually counter-therapeutic, a huge drain on financial resources and causing significant harm to offer opioid intervention in the majority of patients that are currently receiving them.....but clinicians view "more" as better value, and more clinically valid, than doing nothing despite evidence to the contrary.

I therefore call out to all clinicians that next time you consider providing "the best quality" please consider instead whether you are providing the greatest value. TKR's are without doubt high value procedures and they make a huge difference in peoples lives.  However, if you offer them to patients who could otherwise have seen similar gains in pain and dysfunction from more cost-effective, conservative measures, you see a significant reduction in value.  The key is that the level of intervention offered should be appropriate for the needs of that patient.  For many years, physios have been desperate to prove that not every patient with radiological signs of OA, pain and dysfunction needs surgery.  As the evidence is now available to prove that conservative measures are better value for a cohort of patients with such knee complaints, there has been a shift in CCG's and Provider's creating a level of criteria and a threshold for surgery as a way to ensure best value.